chymatous nepliritis is absent; the skin, may, however, be pale as a result of the
anaemia accompanying the disease. Eczema with distressing pruritus is not
uncommon. Nose-bleed and subcutaneous haemorrhages are frequent and
due to the tendency of the degenerated blood-vessels toward rupture.
Hypertrophy of the left ventricle is quite constant and is evidenced by an
accentuation of the aortic second sound, a physical sign upon which alone the
diagnosis of chronic arterial nephritis may be made in many instances. The
pulse is of increased tension and there is thickening of the walls of the artery.
It is to overcome this increased resistance to the flow of the blood current that
the ventricular hv'pertrophy takes place. Dilatation finally supervenes and
with it there is often a relative mitral insufficiency evidenced by an apical
ventriculo-systolic murmur transmitted into the axiUa; when the dilatation
over-balances the hypertrophy the signs and symptoms of uncompensated
heart disease supervene, such as gallop rhythm, dyspnoea, palpitation and
Disorders of respiration due to the co-existent interstitial inflammation in
the lungs â€” chronic bronchitis and emphysema â€” such as dyspnoea on exertion
and cough are not rare. Sudden attacks of marked dyspnoea, especially
at night or early in the morning and due to sudden attacks of arterial contrac-
tion may occur; oedema of the glottis or of the lungs takes place at times.
Pleural effusion is seldom seen. Cheyne-Stokes respiration may be observed
as a late symptom.
Symptoms referable to the digestive system are common. The tongue is
often coated and the breath may possess a uriniferous odor. Dyspepsia of
various types is frequent and uncontroUable and even fatal vomiting and
diarrhoea have been observed. Fermentation in the small intestine is evidenced
by the presence of indicanuria. The resulting toxic substances, particularly
lactic, butyric, oxybutyric and acetic acids, increase the tendency to the
production of sclerotic changes in the arterial and other systems.
Cerebral manifestations, headache, neuralgic pains and apoplectic seizures
due to intracranial haemorrhages are frequent.
Uraemia is a late symptom and often a terminal one; it is usuaUy accom-
panied by a rise in temperature and may be evidenced by headaches, vertigo,
convulsions, stupor or delirium.
The complications are essentiaUy the same as those of chronic parenchym-
The diagnosis may not be made until the patient has reached the autopsy
table but should any symptoms have arisen during life suggesting the need of
urine examination, the characteristic findings at once suggest the presence of
the disease. The diagnosis is often made by the ophthalmologist and the pres-
ence of continued hio;h arterial tension or an accentuated aortic second sound
CHRONIC ARTERIAL NEPHRITIS. 687
should always lead to suspicion. Differentiation from the later stages of a
chronic parenchymatous nephritis may be difficult; the history will help us
here and the presence of fatty and granular casts is more characteristic of the
The prognosis as to recovery is distinctly unfavorable but the existence of
the disease is not at all incompatible with the prolongation of life for years
and does not interfere with the patient's piirsuits so long as these are properly
regulated. After the appearance of ureemic symptoms the probability of
betterment is little, but under proper treatment, even patients who have not
been seen until the occurrence of these manifestations, may be relieved to a
marked extent. Unfavorable symptoms are convulsions, delirium, coma,
persistent vomiting and diarrhoea.
Treatment. The patient should lead a quiet life both mentally and physi-
cally and all conditions which are likely to put any excessive strain upon the
circulatory system or the kidneys are to be carefully avoided. Moderate
exercise should be advised and with it a life in a temperate climate, or, if the
latter is impossible, careful avoidance of wetting the feet, of exposure to ex-
tremes of temperatiire and to dampness must be insisted upon. Clothing such
as that suggested under the treatment of chronic parenchymatous nephritis
should be worn. Tobacco and alcohol are not permissible but the moderate
use of tea and coffee need not be discontinued.
The proper diet is a mixed one so regulated as to maintain the patient's
nourishment without physiological improvidence. It should contain enough
but not too much of the carbohydrate element and also sufhcient proteid in
readily oxydizable form (beef particularly). The proper proportion of starch
and proteid may be ascertained by chemical examination of the urine, too
plentifiil carbohydrates (especially too much sugar) being evidenced by indi-
caniiria accompanied by intestinal fermentation, and proteid in too large
amount by a superabundance of urates and uric acid. In general the regimen
appropriate in chronic parenchymatous nephritis is suitable here. The
diet lacking in chlorides should be prescribed when dropsical conditions are
present. Moderation in eating as weU as in all other things must be insisted
upon. A moderate amount of water should be taken, one quart (one litre)
daily is usually sufficient; excessive water drinking is to be discouraged since
it increases the fluid elements of the blood and consequently raises blood
pressure, and its excretion puts additional work upon the impaired kidney.
With regard to the kind of water little is to be said; practically the only
essential is that it should be pure. The much-vaunted lithia waters are quite
suitable, not because of the infinitesimal amount of lithia which they contain
but because they are, as a rule, pure; the same may be said of nearly all other
mineral waters. Even though benefit is not to be expected from drinking
the waters, a yearly sojourn at such resorts as those at Poland, Maine, Saratoga,
DISEASES OF THE URINARY SYSTEM.
etc., and similar ones in Europe, is ad^asable when the circumstances of the
A daily warm bath should be taken, but just as chilling the body through
exposure to the inclemencies of the weather may precipitate a ursemic seizure
and should consequently be avoided, the cold bath, and especially the prolonged
sea bath, may bring about this most undesirable occurrence. Turkish and
Russian baths are often beneficial but from these the cold plunge should be
A free mc^i^ement from the bowels should be secured daily by means of saline
laxatives or waters such as Hunyadi Janos, Apenta, etc., and an occasional
course of fractional doses of calomel may be prescribed to advantage, par-
ticularly if intestinal autointoxication due to fermentation and lack of
elimination is present. The administration here of intestinal antiseptics
is also necessary as under like circumstances in chronic parenchymatous
The anaemia necessitates the use of tonics such as iron, quinine, arsenic and
str}xhnine but it must not be forgotten that iron may be harmful in the kidney
of chronic arterial degeneration; it is said to cause headache, interfere with
elimination and predispose to the occurrence of ursmia. On the other hand
tincture of iron chloride is considered by some clinicians of marked value
in the anaemia of chronic nephritis; it is recommended in doses of 30 to 60
minims (2.0 to 4.0) three times a day and is said to have the additional effect
of lessening arterial tension. In moderate ansemia of chronic arterial neph-
ritis the elixir of iron, strychnine and quinine of the National Formulary is
an excellent preparation.
One of the most important considerations in the treatment of this disease
is the opening of the arteries by means of the vaso-dilator drugs. By this
measure we relieve the h^-pertrophied and over- worked heart and increase the
blood supply and consequently the nutrition of ever}'- organ and tissue of the
body. The nitrites are most useful here especially er}^throl tetranitrate â€”
which though a nitrate has an analogous action to this series of drugs; this agent
when given in doses of J a grain (0.032) achieves its maximum effect in about
one hour; this effect persists for about six hours, consequently by giving four
doses during the twenty-four hours we can keep the patient's arteries properly
open. Tolerance to this drug is not easily estabhshed and its administration
can be continued for long periods. It is best prescribed in the form of pills
with kaolin or lycopodium as an excipient for if it is mixed with an ox}-dizable
substance it will explode. Glycer}d nitrate is second in its usefulness only to
ervthrol tetranitrate but is inferior in that its effect is less persistent, lasting
but from two to three hours. It must, then, be given at frequent intervals in
order that its action shall be continuous. The dose varies with different pa-
tients and should be regulated according to the effect produced. One should
THE AMYLOID KIDNEY. 689
usually begin with y-^-o of a grain (0.0006) which may be repeated at frequent
intervals, the patient being watched meanwhile for toxic symptoms such as
dizziness, flushing of the face, a feeling of fulness in the head and headache.
Sodium nitrite is another usefiil drug of this class but is difl&cult to obtain in a
state of purity, being almost always contaminated by nitrates. Its maximum
effect is reached in two hours and lasts from four to six hours; its dose is from
3 to 5 grains (0.2 to 0.33). In employing the vaso-dilator drugs the object is
to relieve the heart by reducing the arterial tension and to lessen the tendency
to arterial rupture. It is, however, necessary to provide against too great
lowering of the blood pressure for if this happens cedema and effusions into
the serous sacs are likely to take place.
The already increased amount of urine of the early stages renders the use
of diuretics unnecessan' but late in the disease they may be employed as in
chronic parenchymatous nephritis.
Haemorrhages are treated as when occurring in other conditions; apoplectic
attacks necessitate the application of an ice helmet, venesection if the blood
pressure is high, the administration of potassium iodide in the later stages and
the employment of the other measures suggested under the treatment of
apoplexy. Bleeding from the mucous membranes should be treated according
to the usual methods. Benefit is usually gained by gi^^ng calcium lactate
in doses of 20 grains (1.33) three times a day for a short period. Other
complications should be managed as when occurring independently.
Uraemia is handled according to the methods suggested under the treat-
ment of acute and chronic parenchymatous nephritis.
In other regards than those mentioned the treatment of chronic arterial
degeneration of the kidneys is identical with that of arteriosclerosis in general
The treatment of this form of nephritis by means of decapsulation of the
kidney is entirely useless as may be plainly seen from a consideration of the
nature of the disease. The general arterial system being profoundly affected
treatment directed only to the kidneys must of necessity be of little avail.
THE AMYLOID KIDNEY.
Synonyms. Lardaceous Disease; Waxy Degeneration.
Definition. A chronic degenerative process occurring in the kidneys, and
in other organs and tissues at the same time, and characterized by an infil-
tration of the organ with an albuminous substance which becomes mahogany-
brown in color when wet with tincture of iodine.
.Etiology. This affection occurs as a resiilt of chronic suppurative processes
especially those involving bone, such as ostoemyelitis of pyogenic, syphilitic
or tuberculous origin; in tuberculosis of long standing; in S}^hilis; in gout,
690 DISEASES OF THE URINARY SYSTEM.
chronic plumbism and leucaemia. It is very frequent in Pott's and hip-
Pathology. The amyloid kidney is large, pale in color and of smooth
surface. If the condition is uncomplicated by interstitial changes the capsule
is not adherent; the stellate veins may be plainly visible. On section the cortex
is seen to be thickened, pale, firm, and may present a characteristic lustre;
the glomeruli are prominent. The pyramids are not enlarged and are deep
red in color. Upon smearing the cut section with tincture of iodine the
mahogany-brown coloration above alluded to appears; in later stages and
when the amyloid change is associated with interstitial increase of connective
tissue, the kidney is small, its capsule is adherent and its cortex narrowed.
The hyaline degeneration first involves the Malpighian tufts and the blood-
vessels; later the tubules may become affected. Microscopically the degen-
eration is seen to involve both the interna and the muscular coat of the blood-
vessels, these are so thickened as to, in certain instances, wholly obliterate
the lumen of the vessel. The infiltration of the straight tubules begins in the
membrancB propria and the tubules may contain waxy casts. The epithelium
may be in a state of fatty degeneration and glomerulitis and thickening of
Bowman's capsule are often present.
Symptoms. These are not particularly characteristic and are apt to be
masked by those of the primary disease. The urine is pale in color, increased
in quantity and low in specific gravity. Albumin is usually present, often
in large amount; globulin also may be found. Casts are frequent and are
usually hyaline, although fatty and granular casts are not seldom present as
Dropsy is not an uncommon symptom especially in anaemic and emaciated
patients. It is usually only moderate in degree and affects only the lower
limbs. Diarrhoea is frequent and enlargement of the liver and spleen may be
observed due to the accompanying amyloid degeneration of these organs.
Cardiac and arterial changes occur in those instances where the amyloid
condition is associated with one of the varieties of chronic nephritis; under
such circumstances they are the rule and with them are the other symptoms
of chronic nephritis.
The diagnosis is made upon the concurrence of the urinary changes with
the primary and causative disease. The presence of hepatic and splenic
enlargement are important aids. We should suspect the amyloid kidney in
all instances of chronic suppurative or wasting disease associated with increased
iirine of low specific gravity and containing albumin and hyaline casts. From
the two forms of chronic nephritis amyloid degeneration may be separated by
the absence of cardiac and arterial manifestations, the lack of uraemic and
ophthalmic symptoms, and by the condition of the urine.
The prognosis, while it depends in great measure upon the causative affec-
SUPPUEATIVE NEPHRITIS, PYELONEPHROSIS AND PYELITIS. 69I
tion, is usually unfavorable; it should be unnecessary to state that the amyloid
changes are permanent.
Treatment. Prevention consists in the early and proper treatment of
syphilis, suppurative bone disease and of the other conditions in which amy-
loid degeneration of the kidney is likely to make its appearance. In all such
frequent urinary examinations should be made and upon the appearance of
albuminuria the question of radical removal of the cause should be considered;
this, of course, is possible in a limited number of cases such as in osteomyelitis
of a limb, tuberculosis of the knee-joint and the like.
The treatment of the amyloid condition of the kidney occurring as a com-
plicating disease is that of the condition to which it is secondary. Anti-
syphilitic and antituberculous treatment should be persistently continued so
long as symptoms indicating the necessity for their continuance exist. The
general condition of the patient should be maintained in the best state possible
by means of the employment of nourishing food, particularly milk and cream,
of codliver oil, iron, strychnine and quinine and other tonics, and by insis-
tence upon a life in the open air, with proper exercise, and if necessary, change
Amyloid disease of the kidney after the disappearance of the primary disease
should be treated by the measures, dietetic, hygienic and medicinal, advised
under the section devoted to the treatment of the chronic nephritides (q.v.).
SUPPURATIVE NEPHRITIS, PYELONEPHROSIS AND PYELITIS.
Synonyms. Surgical Kidney; Suppurative Interstitial Nephritis; Septic or
These conditions being almost invariably very closely associated and almost
wholly surgical in treatment, may be considered together.
Suppurative nephritis is a pyogenic inflammation of the kidney resulting
from infection with the bacteria of suppuration which have reached the organ
through the blood current or more usually by an ascending inflammation of
the urinary tract. In the latter instance there is first an inflammation of the
pelvis of the kidney â€” a pyelitis â€” which later spreads to the organ itself,
becoming a pyelonephritis.
.Etiology. As a predisposing cause residual urine in the bladder is most
important; this undergoes decomposition and thus becomes a favorable medium
for the multiplication of bacteria, infection from which ascends the ureter, in-
volves the pelvis of the kidney and finally the kidney itself. Kidney stone may
so irritate the organ as to render its resistance less to bacterial infection and as
a consequence a suppurative process may occur. Infective ureteritis, cystitis
or urethritis from any cause may spread backward to the pelvis of the kidney
and ultimately involve the organ. A very common cause of cystitis and sub-
692 DISEASES OF THE URINARY SYSTEM.
sequent infection of the kidney is the introduction of dirty sounds or other
instruments into the bladder.
Embolic infection through circulatory channels may take place in malig-
nant endocarditis or pyaemic conditions of any kind, and traumatism, operative
or otherwise, may so interfere with the resistance of the organ that it becomes
an easy prey to infection. Exposure and the infectious diseases act as causes
in the same way. Suppurative kidney disease also occurs secondary to malig-
nant and other tumors of the organ.
The infective organisms which have been found in the pus from the kidneys
or in the uiine and have been considered as causes of the process, are the
tubercle bacillus, the bacillus proteus, the colon bacillus, the streptococcus
and the staphylococcus.
Pathology. In pyelitis due to ascending infection, the mucous membrane
lining the kidney pelvis, is swollen and congested, a grayish false membrane
may be present. Dilatation of the pelvis and of the calices, and flattening
of the papillae may take place. The pelvis often contains purulent urine.
As a result of the infective process in the pelvis of the organ extension into
the kidney itself may follow (pyelonephritis) ; the distention finally may result
in atrophy of the substance of the organ until the entire kidney becomes a
mere sac of pus surrounded by a shell of renal tissue (pyonephrosis) ; in certain
instances if there is an obstruction to the flow of pus from the organ, the for-
mer may become cheesy and at times may undergo calcareous degenera-
Ascending tuberculous inflammation first involves the apices of the pyra-
mids; at first the process is limited but ultimately the kidney undergoes
the changes described above, caseous and calcareous degeneration of the
purulent contents of the organ being common.
Metastatic infection of the kidney is evidenced by the occurrence within
the organ of single or multiple pus foci of var3nng size. These are dissem-
inated through the cortex and may coalesce to produce larger abscess cavities
which destroy the structure of the organ and may ultimately unite to convert
the kidney into a sac of purulent matter.
Symptoms. These, aside from the m-inary appearances, are often vague.
Pain and tenderness in the lumbar region or deep in the abdomen are often
present but may not appear even when the kidney is markedly diseased.
Impacted calcuh cause pain, which is usually intermittent in type, at the
site of the obstruction. Chills, fever and sweating are often observed as a
result of the septic condition. The chills are often regularly intermittent
and resemble malarial paroxysms. In the tuberculous infections the tem-
perature frequently, as the disease progresses, becomes of hectic character.
The pulse rate is increased.
Prolongation of the inflammation results in progressive weakness and
SUPPURATIVE NEPHJEIITIS, PYELONEPHROSIS AND PYELITIS. 693
emaciation. Metastatic abscesses and general p^^semia may result. Tuber-
culous pyelitis sometimes runs a course resembling that of enteric fever.
Dyspnoea with cerebral symptoms may occur and even death in coma has
been observed and has been considered to be the result of absorption of
toxic substances from the urine (ammonisemia).
The urine contains pus in variable amount; this substance may be
whoUy absent, if but one kidney is diseased, due to a temporary \ireteral
obstruction. There may be sudden great augmentation in the quantity of
the pus due to ruptiire of an abscess and the discharge of its contents. The
pus may contain fragments of kidney tissue if the inflammation is progressing
rapidly. The quantity of the urine at the beginning may be diminished but
in chronic cases it is often increased. The specific gravity is low rather than
high and the reaction is not constant; it depends upon the micro-organism
causing the disease and upon the presence or absence of cystitis which is usu-
ally accompanied by an alkaline urine. With the pus, red blood cells are also
present, though usually in smaU number. Albumin is present varying with
the amount of pus and red blood cells, although its quantity may be greater
than can be accounted for by these elements if there is co-existent parenchym-
atous nephritis. In the presence of this complication pus casts and those
of other varieties are observed. The urine contains a certain amount of
mucous and usually numerous epithelial cells. The presence of kite-shaped
epithelial cells in considerable number is very suggestive of involvement
of the renal pelvis, although a few of these are often observed when cystitis
is the only lesion.
Physical examination often reveals tenderness in the lumbar region of
the affected side and palpation and percussion may give evidence of a more
or less distinct tumor of varying size.
The diagnosis is simple when hsematuria and pyuria result from injury
of the region of the kidney and should always be suspected when with cystitis
there is persistence of pus in the urine with tenderness over the kidney. Cysto-
scopic examination may aid in the diagnosis and ureteral catheterization will
definitely prove whether the pus is coming from the renal pelvis. The specific
cause of the inflammation can be proven only by bacteriological examination.
Staining of the sedimented urine from specimens obtained by ureteral cathe-
terization may reveal the presence of the tubercle or other baciUi and if this
fails, inoculation experiments should be undertaken.
The prognosis varies with the cause of the disease. Pyaemic cases are
usually rapidly fatal while those complicating the infectious diseases usually
recover. Tuberculous pyonephrosis may result in recovery but with the
kidney converted into a caseous or calcareous mass. The kidney which is
converted into a pus sac may rupture into the peritonseum and any intercur-
rent disease in a patient afflicted with kidney infection is quite likely to ter-
694 DISEASES OF THE URINARY SYSTEM.
minate unfavorably. In fine it may be said, however, that in unilateral sup-
purative disease of the kidney, when not associated with other affections and
when diagnosticated early in its course, nephrotomy or removal of the organ
offers excellent hope of recovery.
Treatment. The importance of early surgical interference cannot be
over-estimated and the same may be said of the employment of the scientific
methods of diagnosis by means of ureteral catheterization which have recently
been perfected. Unilateral tuberculosis calls for removal of the organ, and
abscess due to other causes, when sufficient renal tissue to functionate remains,
for nephrotomy and drainage. The treatment of pelvic inflammations by
means of antiseptic lavage through the ureteral catheter has been advocated
and co-existent cystitis should also be treated by irrigations.
For the pain we may employ hot compresses, the turpentine stupe, dry
cupping or the mustard paste, kept on until the skin is well reddened, then
removed to be reappHed when the blush has faded. If severe, this symptom